NCLEX-RN
NCLEX RN Practice Exam Questions
Extract:
Question 1 of 5
The nurse is caring for a client who is disoriented. To avoid using restraints, the nurse chooses alternative methods to help keep the client oriented. Which interventions would the nurse use for this client? Select all that apply.
Correct Answer: A,C,D,E
Rationale:
Toileting routines, medication review, familiar items, and calendars/clocks promote orientation. Minimizing visitation may isolate the client, and room placement is less relevant.
Question 2 of 5
The nurse is caring for a client post-op femoral popliteal bypass graft. Which post-operative assessment finding would require immediate physician notification?
Correct Answer: D
Rationale: Loss of distal pulses indicates potential graft occlusion or arterial compromise, a surgical emergency requiring immediate notification.
Question 3 of 5
Which developmental milestone puts the 4-month-old infant at greatest risk for injury?
Correct Answer: D
Rationale: Rolling over at 4 months increases the risk of falling from elevated surfaces like changing tables, a common cause of injury.
Question 4 of 5
The nurse is assigned to work with the parents of a retarded child. Which of the following should the nurse include in the care plan for the parents?
Correct Answer: D
Rationale: assessment, this will help the nurse to know where the family is in regard to grieving, coping, etc.
Question 5 of 5
The client returns to the recovery room following repair of an abdominal aneurysm. Which finding would require further investigation?
Correct Answer: B
Rationale: Low urinary output (20 mL/hour) may indicate renal impairment or hypoperfusion, requiring further investigation.